Men's experiences of living with obesity

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M A S T E R ' S T H E S I S

Men´s Experiences of Living with Obesity

Sebastian Gabrielsson

Luleå University of Technology D Master thesis

Nursing

Department of Health Sciences Division of Nursing care

2008:018 - ISSN: 1402-1552 - ISRN: LTU-DUPP--08/018--SE

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Institutionen för hälsovetenskap Avdelningen för omvårdnad

Men’s experiences of living with obesity

Omvårdnad D, 61-80 poäng Delkurs 3 – Läsåret 05/06 Vetenskapligt arbete, 10p

Författare: Sebastian Gabrielsson

Handledare: Lisa Skär Examinator: Stefan Sävenstedt

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Abstract

The aim for this study was to describe men’s experiences of living with obesity. By exploring the patients’ perceptions it might be possible to gain an understanding of the attitudes that influence health care encounters and quality of life for patients with obesity. A qualitative design was used. Nine adult men with BMI ≥30 were interviewed using semi-structured interviews. Interviews were transcribed verbatim and analysed using thematic content analysis. The result described living with obesity as struggling for well-being. The obese men described experiences of being limited, being oversized, being content with ones weight yet desiring weight-loss and being seen as obese. The obese men’s desire to lose weight and their feelings of discomfort in situations focusing on their obesity was understood as a result of implicit anti-obese bias and the internalization of the social stigma of obesity.

Keywords: men, experiences, obesity, attitudes, stigma,

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1. Introduction

1.1 Obesity

The World Health Organization (WHO) has declared a global epidemic of obesity (WHO, 2000). According to WHO the prevalence of obesity is increasing, not only in developed countries but also in developing countries, where it co-exists with under nutrition. The prevalence of obesity in Sweden is still low in an international perspective, but data collected from 1985 to 2002 shows that the prevalence for obesity in Swedish men has increased from 6.4% to 14.8% (Neovius, Jansson & Rössner, 2006). Obesity is the result of an imbalance in energy intake and energy expenditure for a longer period of time (WHO, 2000; The Swedish Council on Technology Assessment in Health Care [SBU], 2002). Both genetic and environmental factors influence the development of obesity. According to The Swedish Council on Technology Assessment in Health Care, adoption and twin studies stress the biological influence, and the tendency to gain weight as a result of excess energy intake varies between individuals (SBU, 2002). They also conclude that environmental factors are essential for developing obesity, and that an increased number of obese individuals is the inevitable result of high availability of energy rich food combined with small incitements for physical activity. Since the risk of becoming obese increases if a friend, spouse or sibling becomes obese, obesity appears to spread trough social ties (Christakis & Fowler, 2007). Obesity often develop after child birth or menopause which might explain why there are more obese women than men (SBU, 2002), while men are more overweight than women (WHO, 2000). There is also a connection between obesity and cessation of smoking, medical treatment and belonging to a less privileged social group (SBU, 2002).

Obesity can be defined as abnormal or excessive fat accumulation to the extent that health may be impaired. Body mass index (BMI) is regarded to be the most useful tool for measuring obesity at a population level (WHO, 2000). BMI is a person’s weight in kilograms divided by the square of the person’s height in metres. The cut-off point for obesity is widely accepted to be BMI ≥30 (WHO, 2000). Around this point the risk for serious obesity-related complications increases significantly (SBU, 2002). BMI has limitations when it comes to identifying obese individuals, since it is unable to separate weight associated with fat from weight associated with muscle. Also, it does not take into account the distribution of body fat.

Abdominal fat is strongly connected to negative health consequences. By measuring waist circumference obese individuals with increased risk of obesity-related illness can be

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identified. There are other methods to achieve a more detailed characteristic of the state of obesity, but they are generally considered too costly and impractical to apply to be used in research (WHO, 2000). The value of self-reported weight is limited since when asked people tend to underestimate their own weight (Neovius et al., 2006).

Obesity is a chronic condition that threatens health, but there is a lack of consensus on whether obesity should be considered a disease or as merely a risk factor for disease (SBU, 2002). Obesity is strongly connected to increased health risks, morbidity and mortality (WHO, 2000; SBU, 2002). The most common obesity-related complications are type 2 diabetes mellitus, high blood pressure, myocardial heart infarction, gallstones, sleep apnea, joint problems, some cancers, pregnancy related problems and infertility (SBU, 2002).

Obesity is also associated with, dyslipidemia, stroke and numerous other medical conditions (WHO, 2000). Prevention of obesity is essential but changes of life-style are difficult to achieve. The Swedish Council on Technology Assessment in Health Care concludes (SBU, 2004) that school-based programs focusing on changed eating and drinking habits and physical exercise can prevent the onset and development of obesity in children and youth, and that measures to improve diet and physical exercise also can prevent obesity in adults. The basis of treatment of already obese individuals is a reduction of energy intake and increase of energy expenditure, while the main problem is to maintain initial weight loss (SBU, 2002).

Bariatric surgery has positive and well documented long-term effects such as weight-loss and decreased overall mortality (Sjöström et al., 2007). Dietary treatment, very low caloric diets, physical activity and pharmacological treatments all result in various degree of initial weight loss although the long term effects are moderate or uncertain while there is no documented evidence for the effect of alternative medicine (SBU, 2002). The evidence for nurse led interventions aimed at managing obesity in primary care are unclear, and the percentage of patients achieving significant weight-loss after entering a nurse led program might be as low as 10% (Brown & Psarou, 2007).

The Swedish Council on Technology Assessment in Health Care establishes a connection between obesity and a decreased quality of life (SBU, 2002). People with obesity have a lower physical functioning related to impaired ability to walk and move, and they have a high degree of bodily pain. They rate low on scales measuring physical and mental health compared to normal weight people. In some areas perceived body weight have a larger impact on quality of life than BMI (Burns, Tijhuis & Seidell, 2001). Perceived overweight is

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connected with impaired health and vitality. According to Burns et al. (2001) this can be understood as a result of the social stigma of obesity and not as an actual result of overweight and obesity. Men and women with obesity pose an increased risk of being subject to bad treatment, both in health care encounters and society at large. People with obesity are discriminated against in the workplace and have lower incomes (SBU, 2002). Stigmatization and discrimination has been documented in the areas of employment, education and health care (Puhl & Brownell, 2001). In work settings people with obesity are subject to prejudice, insensitivity and inequity. They are less likely to be hired, have lower wages, lower promotion prospects and risk being fired or pressured to resign because of their weight. Overweight women receive less pay for the same work, while overweight men sort themselves into lower level jobs.

One of the greatest challenges for health care personnel is to gain and maintain the trust of those who turn to them for medical treatment, relief, comfort and guidance. Health care providers often rely on patient satisfaction surveys as a measurement of how well they live up to patients’ expectations on quality of health care encounters. High levels of patient satisfaction are linked to patient loyalty, treatment adherence and positive health outcomes, while low quality of health care encounters may contribute to treatment seeking delay which is often associated with negative health outcomes (Turris, 2005). Healthcare providers do not differ from the rest of society in characterizing overweight individuals as repulsive, disgusting, weak and lacking self-discipline (Rogge, Greenwald & Golden, 2004). Physicians consider obese patients to be lazy and lack self-control (Puhl & Brownell, 2001). Obese women have less positive attitudes toward physicians and are frequently berated about their weight and treated disrespectfully by them (Drury & Louis, 2002). Many nurses have negative attitudes against patients with obesity (Brown, 2006). Attitudes and treatment of health care professionals dissuades obese women from seeking health care, and an increase in BMI is associated with an increase in delay/avoidance of health care (Drury & Louis, 2002). Rogge et al. (2004) compares the way society treats obese people with the concept of civilized oppression and suggests that obese patients’ fear of oppressive encounters with physicians might result in treatment seeking delay. They also emphasise nurses’ responsibility to recognise oppressive, denigrating and demoralizing encounters. Walsh and Kowanko (2002) also stress the moral responsibility of health care personnel to treat the patient in such a way as to nurture the relationship with the patient. The nurse-patient and physician–patient

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relationships are by necessity unequal since the patient is always in a state of dependence towards the health care provider.

Research on health care professionals’ attitudes towards obese patients rarely covers the patients’ perspective (Brown, 2006). According to Brown, exploring the patients’ perceptions is essential in order to understand the attitudes that influence health care encounters and quality of life for patients with obesity. There is a difference between patient satisfaction and patient experience (Williams, Coyle & Healy, 1998). A patient might describe negative experiences of a health care encounter but still give high ratings in a satisfaction survey.

According to Williams this reflects an attitude that the individual personnel are doing their best during the circumstances. Thus, research aiming to describe patients views on the quality of care should focus on the patients’ experiences. Research on men with obesity’s experiences of health care encounters might be hard to achieve since there are difficulties finding male interviewees (Rogge et al., 2004). What research does exist suggests a difference in the experiences of men and women. Men are less prone to the stigma of obesity than women are (Drury & Louis, 2002). Women report a greater number and a greater variety of negative experiences than men (Cossrow, Jeffrey & McGuire, 2001). Research on patient satisfaction in general suggests a difference in how men and women perceive quality of care. Wilde, Larsson and Starrin (1999) showed that female patients more than male patients were dissatisfied with rude encounters and being dehumanized. Male patient dissatisfaction was more often related to waiting and medical treatment. Foss and Hofoss (2004) found that female patients felt disbelieved and male patients felt maltreated. This is understood as a result of female patients interpreting negative experiences as being unheeded and male patients interpreting them as being maltreated.

The prevalence of obesity is increasing worldwide. Obesity is connected with a decreased quality of life and numerous obesity-related complications. People with obesity are subject to prejudice and discrimination in several areas of life, including health care. Negative attitudes and disrespectful treatment of health care professionals might lead to treatment seeking delay and health care avoidance. By exploring the patients’ perceptions it might be possible to gain an understanding of the attitudes that influence health care encounters and quality of life for patients with obesity. A review of existing literature indicates a lack of research describing the experiences of men with obesity.

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1.2 The aim of this study

The aim of this study was to describe men’s experience of living with obesity.

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2. Method

2.1 Design

According to Polit and Beck (2004) qualitative research is useful in describing dimensions, variations and importance of experiences. Qualitative research can be used to explore a phenomenon in order to gain a full understanding of it, its various manifestations and underlying processes. In order to fulfil the aim of this study a qualitative approach was used.

2.2 Participants and procedure

In order to select rich cases that offer strong examples, participants was selected using a purposive sampling (Polit & Beck, 2004). Sample size in qualitative research is a question of obtaining enough information in relation to the aim of the study and the sampling strategy used (Polit & Beck, 2004). This study aimed to gather a minimum of eight interviewees. The interviewees consisted of adult men with a BMI ≥ 30. Permission was granted to use the registry of the Northern Sweden MONICA project to gather participants. The Northern Sweden MONICA project is a continuation of the multinational MONICA project co- ordinated by the WHO and aimed at monitoring trends and determinants for cardiovascular disease. Potential interviewees were selected amongst adult men who had a registered BMI ≥ 30. Interviewees were selected in order to achieve variation in age and BMI. Letters asking for participation (appendix 1) was sent out to 40 potential interviewees during a period of six months. Those who agreed to participate or to be contacted for further information was contacted by phone and given the opportunity to obtain more information and to withdraw from the study at any time. Finally nine men agreed to participate in the study (Table 1).

Table 1. Participant characteristics

Age 49 56 57 60 65 66 67 68 72 M=62.2

BMI 42.21 33.27 32.37 33.26 30.62 30.86 31.05 33.39 31.41 M=33.16

2.3 Data collection

Data was collected using semi structured interviews. Semi structured interviews give the informant opportunity to speak freely in their own words while ensuring that the topics relevant for the study are covered (Polit & Beck, 2004). An interview guide (appendix 2) was

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used. The interview guide was revised and more topics added after the first interview. The main questions were Can you tell me about your experiences of living with obesity? Can you tell me about your experiences of encounters within health care? and In what ways have you experienced that your weight has influenced the treatment given to you? Several follow up questions were used such as Can you tell me about a situation in which you were given a bad treatment? The main topics were definition of obesity, definition of bodily constitution, employment, leisure time and relations. Interviews were tape recorded and transcribed verbatim by the author. The interviews took place at a location of the participants’ choice in order to make them feel as comfortable as possible. The length of the interviews varied between 15 and 45 minutes. In three cases the face to face interview was followed by an additional interview by phone.

2.4 Data analysis

Content analysis makes it possible to make valid inferences from interviews in order to describe experiences (Downe-Wambolt, 1992). It is based on a holistic analysis (Baxter, 1994) and takes into account the contextual environment of the data (Downe-Wambolt, 1992).

In this study, the data was analyzed using thematic content analysis as described by Downe- Wambolt (1992) and Baxter (1994). The unit of analysis consisted of the transcribed interviews. The interviews were read through several times. Meaning units corresponding to the aim of the study were identified. The meaning units were condensed and coded, and the codes were used to create a system of subcategories and categories. From the category system a theme was derived. The interviews were read through again to confirm the theme.

According to Baxter (1994) themes are treads of meaning that occur in domain after domain.

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Table 2. Example of the analysis process

Meaning unit Condensation Code Subcategory Category Theme

I have been trying to lose weight and have lost about five kilograms in two years it has been going up and down I am out walking for an hour every other day and then there’s chores like chopping and bringing in firewood

Trying to lose weight by walking and chopping wood

Weight

loss A wish for a

change Being

content yet desiring weight-loss

Struggling for well-being

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2.5 Ethical considerations

This study was carried out as part of a larger research project for which approval was obtained from the regional ethics committee. A letter asking for participation (appendix 1) was constructed with ethical considerations taken addressing the concept of informed consent (Polit & Beck, 2004). The informants were asked to agree in writing that they had taken part of and understood information about the study and their participation, including their right to withdraw from the study at any time. There was a risk of potential informants feeling offended by being singled out as obese. This risk was minimized by only addressing men diagnosed with obesity and with previous experience of participating in health related research. The potential benefits of the study was considered being of greater value than the risk of negative consequences for the informants.

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3. Result

3.1 Struggling for well-being

The thematic content analysis resulted in four categories from which a theme was derived (Table 3). The result described living with obesity as struggling for well-being. The obese men described experiences of being limited, being oversized, being content with ones weight yet desiring weight-loss and being seen as obese.

Table 3. Result of thematic content analysis

Theme Category Struggling for well-being Being limited

Being over sized

Being content yet desiring weight-loss

Being seen as obese

3.2 Being limited

This category described the experience of being physically limited by ones weight and suffering from obesity-related complications, and being limited in the choice of recreational activities. The result described that the men with obesity experienced physical limitations.

They had difficulties bending down to tie their shoe laces. The weight was described as a heavy burden. A poor physical condition was seen as being weight-related and made it hard to walk or run for a longer distance. The men described their experience of certain work tasks being more difficult to accomplish or feeling more strenuous. The obese men described having trouble getting in and out of vehicles because of their weight. They also suffered from obesity related-complications such as diabetes, high blood pressure, joint problems, back pain, snoring and atrial fibrillation. The men in this study considered these conditions to be directly or indirectly linked to their weight.

… walking is really strenuous work, if you walk a distance you start breathing and panting and it hurts everywhere …

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The result also described choosing to take part in sports and physical exercise despite a lack of genuine interest. Recreational activities were seen as a means to loose or avoid gaining weight. It was also considered as a way to make it possible to indulge in eating and drinking without facing the negative consequence of weight gain.

… I have always been obliged to physical exercise in some form to avoid weight gain, something I might not have done otherwise …

3.3 Being oversized

This category described experiences of being oversized in relation to clothes, furniture and health care equipment. Consumption habits were affected by obesity. It was often difficult to buy desired clothes since they might not be available in adequate sizes. As a result certain shops were avoided since they usually did not carry adequately sized clothes. When purchasing new furniture it was important that they were of good quality so they did not break in pieces. The obese men also described difficulties getting into tight areas because of their bodily constitution.

... the times you suffer from it is when you see a nice coat that you want to buy, it doesn’t come in your size and you must choose from other coats…

The men described also that health care equipment not always was adapted for obese people.

The men encountered undersized patients clothing, uncomfortable hospital beds and inadequately sized cuffs. These experiences were linked with feelings of being uncomfortable when ones obesity was made obvious. Coping strategies described included bringing personal clothes to hospital and monitoring blood pressure at home with a private cuff.

… a simple thing like cuffs, if you have somewhat larger upper arms they have to run around searching for a bigger cuff, almost every health care facility have serious problems

performing a simple blood pressure check….

3.3 Being content yet desiring weight-loss

This category described the experience of being content with ones weight, yet wishing for a change. The result showed that most of the interviewed men did not consider themselves

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obese. The men in the study objected to the term obese. Instead they defined themselves as overweight, large or heavy. The result showed the obese men undertook varying and repeated actions in order to lose weight. These included changed eating habits like eating slowly, trying out healthier recepies, stop drinking milk or going on weight loss cures. They also performed different forms of physical exercise like cycling, walking, skiing or going to a gym. The result of weight loss attempts differed, but several of the men described having lost weight since taking part in the MONICA project. By losing weight they hoped to improve general well being, general health and to be less restrained. The obese men wished to be like everybody else, they wanted to lose weight or, if they already have lost weight, maintain their new weight.

… I have never seen myself as obese, of course you notice it when you pinch yourself and when your clothes shrink…

3.4 Being seen as obese

This category described the experience of being perceived as obese and subsequent consequences in different areas of living.

The result described how men with obesity believed they were considered less intelligent and were being looked down upon because of their weight. They had received approving as well as critical comments about their weight from friends and relatives. They also described how weight loss attempts and physical exercise was something that could be carried out together with co-workers, friends and spouses, but other than that the result did not describe experiences where obesity affected the informal relations.

… we have discussed it and we are both in the same position, we try to help each other exercise and cut back …

The result described various experiences of encounters with health care personnel. Men with obesity sometimes experienced that health care personnel treated them as individuals. They were being listened to and being taken seriously. Personnel spent time with them, talked to them, took interest in their well-being, and gave praise for compliance with prescriptions. The men in the study described that health care professionals sometimes did more than what could

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be expected of them, i.e. follow up phone calls at home or regular visits by physicians while at hospital. However, the result also described men with obesity not being listened to and not being taken seriously. They experienced not being seen as individuals but instead seen as primarily obese, and that all their problems were seen as obesity related. The result described experiences of health care personnel remarking on weight and giving information on possible health gains to be made from losing weight. This was sometimes seen as either irrelevant or unnecessary and caused stress and discomfort, but it could also be considered as helpful and professional when relevant to a medical condition. The men described avoiding seeking health care in fear of symptoms being referred to obesity. Some of the obese men explained disrespectful treatment by health care personnel as a consequence of patient’s attitudes and behavior.

… everything that highlights your size and weight, like getting weighed, is embarrassing because you would rather be of normal weight…

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4. Discussion

4.1 Result discussion

The aim of this study was to describe men’s experiences of living with obesity. The result describes the experience of struggling for well-being and shows that living with obesity means being physically limited, being limited in consumption choices and in choosing recreational activities. The result also shows that being obese does not cause many problems in relation to family and friends. The obese men did not necessarily consider themselves obese, and body size in itself was not considered to be a major problem. Yet the obese men had a desire to lose weight. This desire was partly motivated in terms of improved health, but also with a desire to be like everybody else. The most remarkable consequences were found in relation to health care. In these encounters the obese men described negative experiences of their weight becoming the focus of attention.

In order to gain an understanding of why the obese men felt uncomfortable in these situations, it must be remembered that health care encounters take place in the context of a society in which it has been claimed that obese people are the last acceptable targets for discrimination (Puhl & Brownell, 2001). Overweight and obese television characters are associated with negative characteristics (Greenberg, Eastin, Hofschire, Lachlan & Brownell, 2003). The existence of prejudice and discrimination against persons with obesity has been documented (SBU, 2002; Puhl & Brownell, 2001), as has negative attitudes and anti-obese bias among health care personnel (Rogge et al., 2004; Puhl & Brownell, 2001; Drury & Louis, 2002;

Brown, 2006), and even among health care professionals specializing in obesity (Schwartz, O’Neal Chambliss, Brownell, Blair & Billington, 2003). In this study the obese men described some experiences of encountering stereotypes for obese persons as health care personnel automatically referred their symptoms to obesity, but they did not describe experiences of negative attitudes against obese persons. Neither did they describe themselves sharing negative attitudes against or stereotypes for obese persons. Previous research shows that although there is a negative correlation between BMI and anti-obese bias, people with obesity themselves are in no way free from prejudice (Schwartz, Vartanian, Nosek &

Brownell, 2006). Bias can be defined as consisting of stereotypes and negative attitudes.

Attitudes and stereotypes can be implicit or explicit and hence bias can be implicit or explicit.

Bias can result in stigmatization and/or discrimination. The lack of anti-obese bias described

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by the result of this study can be explained by applying the concept of explicit and implicit attitudes as described by Schwartz et al. (2006). Explicit attitudes are consciously acknowledged and expressed, while implicit attitudes are either unaware of or unwilling to report. Implicit attitudes cannot be obtained using self-report measures. There is little relationship between implicit and explicit measures of anti-fat bias (Wang, Brownell &

Wadden, 2004).

The result of this study describes how the obese men felt discomfort in situations highlighting their obesity. This correlates to previous research on obese women that established a direct correlation between BMI and health care avoidance, in which the obese women reported a variety of weight-related reasons for avoidance including having recently gained weight, not wishing to be weighed at the visit, not wanting to undress, or not wanting to be told that they needed to lose weight (Drury & Louis, 2002). Drury and Louis also explored the correlation between avoidance and self esteem, responsibility for weight ideology and satisfaction with healthcare on health care utilization but were unable to establish any statistically significant relationships. In the study at hand the obese men’s feelings of discomfort in situations focusing on their obesity is understood as the result of the obese men’s own implicit negative attitudes against persons with obesity and the internalization of the social stigma of obesity that exists in society. The internalization of the social stigma of obesity has been described by Wang et al. (2004). According to Wang et al. anti-obese bias is unique in the way that members of a distinct group usually view its own members more favorably than they view non-members, but is not true for overweight persons. Wang et al. recognizes several possible reasons for this behavior. Obesity is seen as controllable, and hence people who are unable to lose weight are viewed as lazy, irresponsible and lacking motivation. The refractory nature of weight-loss enhances these beliefs. By providing a medical explanation for obesity the individual’s responsibility for his condition is reduced and so are the negative attitudes towards him.

The result of the present study also describes men with obesity feeling content with their current weight, and being reluctant to define themselves as obese. These findings correlate to previous research on the connection between perceived body weight and quality of life. Burns et al. (2001) found that perceived body weight had a larger impact on quality of life in terms of impaired health and vitality, than did actual BMI, which was understood as a result of the social stigma of obesity. It is not so much obesity in itself that causes impaired quality of life,

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but the stigma of obesity. In the study at hand, the interviewed men’s implicit negative attitudes towards persons with obesity might explain their desire to lose weight while claiming to be content with their current weight.

In conclusion, the result showed that the interviewed men described the experience of struggling for well-being. They were limited by their obesity and suffered from obesity related complications. They had experiences of clothes, furniture and health care equipment not being adapted to their size. The men were content with their weight yet desired weight- loss. The most remarkable consequences were found in relation to consumption and health care. In these encounters the obese men described negative experiences of their weight becoming the focus of attention. The obese men’s desire to lose weight and their feelings of discomfort in situations highlighting their obesity can be understood as a result of implicit anti-obese bias and the internalization of the social stigma of obesity.

4.2 Method discussion

The concept of trustworthiness can be used to judge the truth value of qualitative research (Holloway & Wheeler, 2002). Judgments of trustworthiness are made possible through developing dependability, credibility, transferability and confirmability. To ensure dependability the author has given a thorough account of the research process. Credibility addresses the question of whether the findings are consistent with the perceptions of the participants. Previous research states that men are unwilling to talk of their experiences of obesity (Rogge et al., 2004). This might be understood as a consequence of internalized social stigma of obesity which inhibits men from talking openly about their experiences. To ensure that the interviewed men felt comfortable in the interview situation the interviews took place at a time and location of the participants’ choice. Using BMI as selection criteria for identifying obese men has limitations since BMI is unable to distinguish between fat and muscle mass. Furthermore, a period of time had passed between the collection of weight data and the interviews which open the possibility that some of the interviewed men didn’t actually fill the inclusion criteria at the time of the study. Those who were asked but chose not to take part in the study were more often younger and had a higher BMI than those who participated.

These circumstances limit the transferability of the result to obese men in general. To ensure confirmability data was reviewed by and categories and themes discussed with peers. Trough

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out the research process interpretations and explanations were discussed with a supervisor to minimize the influence of the author’s preconceptions.

4.3 Implications for nursing practice

Nurses play a significant role in the prevention and managing of the growing problem of obesity. Although the evidence for nursing led interventions on weight-loss is limited, it is essential that nurses possess the knowledge and skills to encounter persons with obesity in such a way as to not discourage from further contact with health care. In encountering health care, people with obesity might bear with them their own negative attitudes against obese people, and they might also expect the health care professional to share these negative attitudes. If this is the case, it is not necessary to experience explicit anti-obese bias to have a negative health care experience as a result of negative attitudes against obese persons.

Previous research states that the nurse-patient relationship is by necessity unequal and hence it is the moral responsibility of the nurse to nurture the relationship and recognise oppressive, denigrating and demoralizing encounters (Walsh & Kowanko, 2002; Rogge et al., 2004). In encountering obese patients nurses should strive to identify and erase not only their own anti- obese bias, but also the patients’ bias. Nurses should also take measures to avoid unnecessary focus on the patient’s weight by ensuring that equipment and patient clothing is adequately sized. In order to gain and maintain the trust of obese patients, nurses should apply a non- judgmental and professional attitude when discussing weight-related issues.

4.4 Further research

Further research is needed to confirm, describe and understand the connection between implicit anti-obese bias, social stigma and negative experiences of encounters within health care. Since implicit attitudes and stereotypes are not easily captured using qualitative methods, methodological triangulation combining qualitative and quantitative methods should be applied.

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Williams, B., Coyle, J., & Healy, D. (1998). The meaning of patient satisfaction: an explanation of high reported levels. Social Science and Medicine, 47, 1351- 1359.

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Appendix 1 – letter asking for participation

2006-12-13 Förfrågan om medverkan i forskningsprojekt-

Att leva med fetma, kvinnor och mäns upplevelser

Vid Institutionen för hälsovetenskap, Luleå tekniska universitet startar vi ett forskningsprojekt om kvinnor och mäns upplevelser av att leva med fetma och bemötande inom hälso- och sjukvård. Studien genomförs i samarbete med MONICA-undersökningen i Norrbotten och docent Mats Eliasson vid Sunderby Sjukhus och Umeå Universitet

Urvalet att deltagare har skett från MONICA-undersökningen i Norrbotten år 2004 där du var en av deltagarna. Du gav vid detta tillfälle tillstånd att data skulle få användas i forskning kring diabetes och hjärtkärlsjukdomar samt även för frågor som rör övervikt och fetma. Vi har också fått tillstånd av regionala etikprövningsnämnden i Umeå att kontakta dig och genomföra nedanstående

forskningsprojekt.

Denna förfrågan om deltagande ställs till kvinnor och män som vid MONICA-undersökningen hade ett kroppsmasseindex, även kallat body mass index (BMI), över 30. Studien kommer att genomföras med intervjuer som fokuserar på din upplevelse av att leva med fetma och din upplevelse av

bemötande inom hälso- och sjukvården och beräknas pågå cirka 30-45 minuter. Samtalet kommer att spelas in på band och därefter skrivas ut ordagrant. Dina svar kommer att hanteras så att inte obehöriga kan ta del av dem. Intervjutexterna kommer att bearbetas och sammanställas i en rapport. All

information kommer att behandlas så att ingen person kommer att kunna identifiera vem som har sagt vad i den färdiga rapporten som kommer att redovisas i den internationella vetenskapliga litteraturen så att kunskapen ska komma många till del.

Om Du är intresserad av att delta i vår studie och att bli intervjuad så ber vi dig att skicka svarsblanketten i det bifogade kuvertet inom 14 dagar. Du kommer därefter att kontaktas för att komma överens om tid och plats för intervjun. Deltagandet är helt frivilligt och du kan när som helst avbryta ditt deltagande utan att ange skäl.

Siv Söderberg Lisa Skär

Leg. sjuksköterska Leg. sjuksköterska

Docent, universitetslektor Universitetslektor

Institutionen för hälsovetenskap Institutionen för hälsovetenskap Luleå tekniska universitet Luleå tekniska universitet

Tel. 0920-493818 Tel. 0920-493890

För MONICA-undersökningen i Norrbotten:

Mats Eliasson, docent, överläkare, Sunderby Sjukhus Institutionen för folkhälsa och klinisk medicin, Umeå Universitet

0920-28 34 53, mats.eliasson@nll.se

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Förfrågan om deltagande i forskningsstudie

Jag har informerats om studien och tagit del av medföljande skriftliga informationen. Jag är

intresserad av att delta som intervjuperson i projektet. Jag är medveten om att mitt deltagande i studien är frivilligt och att jag när som helst och utan närmare förklaring kan avbryta mitt deltagande.

Var god kryssa för alternativ enligt din önskan:

 Ja tack, jag önskar delta i studien

 Jag godkänner att bli uppringd för ytterligare information

Namn:__________________________________________________

Adress:__________________________________________________

Telefonnummer: __________________________________________

E-post: ___________________________________________________

Returnera denna svarstalong i bifogat kuvert till Sebastian Gabrielsson, som därefter kommer att kontakta dig. Sebastian Gabrielsson är leg. sjuksköterska och studerar omvårdnad vid institutionen för hälsovetenskap.

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Appendix 2 – interview guide

Berätta om din upplevelse av att leva med fetma.

Hur definierar du fetma?

Hur definierar du din egen kroppsbyggnad?

Hur har din vikt påverkat dig i ditt yrkesliv?

Hur har din vikt påverkat dig på din fritid?

Hur har din vikt påverkat dina relationer?

Berätta om dina upplevelser av bemötande i hälso- och sjukvården.

Berätta om en situation då du blivit bra bemött.

Berätta om en situation då du blivit mindre bra bemött.

Berätta hur ett bra bemötande från personal i hälso- och sjukvården skulle vara?

På vilket sätt har du upplevt att din vikt har betydelse för hur du blivit bemött.

Klargörande följdfrågor:

- Hur kände du då?

- Vad hände?

- Kan du förklara närmare?

- Vad tänkte du då? Kan du ge exempel?

- Vad tror du det berodde på?

- På vilket sätt?

- Hur känns det?

- Vilka konsekvenser fick det?